- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,801.89 / $6,760.83
| Facility | | $1,096.48 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,122.02 / $2,691.53
| Professional | | $676.08 | $1,122.02 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,041.74 / $5,495.41
| Facility | | $1,047.13 | $2,041.74 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,454.71
| Professional | | $1,621.81 | $1,949.84 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,011.87 / $6,760.83
| Facility | | $2,691.53 | $5,011.87 | $6,760.83 |